Current Pediatric Roles in Child Abuse and Neglect Barton D. Schmitt, MD
pediatricians are being called to undertake expanded roles in the field of child abuse and neglect, whether \s=b\ Many
on
as a
practicing pediatrician,
a
hospital\x=req-\
based child abuse consultant, or as a child protection team pediatrician. The practicing pediatrician must consider the diagnosis of child abuse and neglect, confirm the diagnosis, report all suspected cases to child protective services, hospitalize any abused child who needs protection, and provide preventive services. The hospital-based child abuse consultant should provide consultation to primary physicians, report seriously injured cases for the primary physician or surgeon, provide expert medical testimony on difficult to prove cases, teach house staff and medical students about child abuse and neglect, and improve treatment services for abused children who are hospitalized. The child protection team pediatrician will usually become involved in the broader problem of improving team decision making and the interagency system that deals with child abuse and
neglect. (Am J Dis Child 133:691-696, 1979)
Many
pediatricians
are
being
called on to accept expanded roles in the field of child abuse and neglect. The physician may be asked to join a child protection team, to serve as an expert witness for a diffi¬ cult case, or to work for improvement in community services for abusive families. The purpose of the following comments is to review the various levels of involvement of pediatricians in the problem of child abuse and
neglect.
THE PRACTICING PEDIATRICIAN
The practicing pediatrician must be able to competently diagnose the From the Department of Pediatrics, University of Colorado Medical Center, Denver.
Presented at the National Pediatric Conference, Minneapolis, June 17, 1977. Reprints not available.
abuse and neglect of a child. Regard¬ less of how many specialists are trained in this field, the recognition of child abuse will continue to be the responsibility of all primary-care phy¬ sicians and nurses. The pediatrician can also play a role in the prevention and treatment of child abuse. For optimal intervention on behalf of the abused child, the practicing pediatri¬ cian can do the five following activi¬ ties. Consider the Diagnosis of Child Abuse and Neglect
In the multitude of children seen each day, the physician must think about inflicted injuries. This is espe¬ cially important in children less than 2 years of age, where every misdiagnosis carries a great potential for fatal outcome, with repeated abuse. We should think of inflicted bruises before von Willebrand's disease, nonaccidental fractures before osteogenesis imperfecta tarda, and failure to thrive from nutritional deprivation before celiac disease. The private physician will see four to six cases of child abuse and neglect per year but may go through a decade of practice without detecting a single new case of the more exotic diseases. We must keep in mind that at least 100,000 children per year are abused in this country. Of these reported cases, approximately 85% are physically abused, 10% are sexually abused, and 5% are nutritionally abused and show failure to thrive on the basis of under¬ feeding.1 There are at least 2,000 deaths a year. These statistics do not include serious neglect of children that could easily double or triple the total number. Approximately 10% of children younger than 6 years of age seen
by
emergency
for trauma have inflicted.-
room
injuries
physicians that
were
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Confirm the Diagnosis of Child Abuse and Neglect
Sometimes the injury is pathognomonic, such as a handprint, bite mark, belt mark, or cigarette burn. On other occasions, the physician should consid¬
the diagnosis of nonaccidental trau¬ the basis of the implausibility of the history offered as to how the injury occurred. The assessment of the plausibility of the history is always a medical judgment. Profes¬ sionals from other disciplines (eg, social work, psychiatry, law enforce¬ ment, and law) are not trained or expected to make this decision.3
er
ma on
All Suspected Cases to Child Protective Services
Report
The law in all 50 states requires reporting and, thereby, guarantees that adequate family evaluation, treatment, follow-up, and proper use
of the court will occur in these cases. These actions decrease the chance of recurrence and death from abuse. No matter how accomplished a counselor he is, the physician is foolhardy to ever assume that he can manage all aspects of such cases by himself. Most hospital social workers are willing to make the verbal report for the physi¬ cian and to serve as an ongoing liaison with child protective services. Some physicians may be reluctant to report such cases because they are too close to the family, do not want to become involved with a court action, or are not absolutely certain of the diagnosis. Such a physician should refer his patient to a consultant or hospital that is willing to meet the legal obligations for suspected abuse. Abused Child Who Needs Protection During the Initial Stage of Evaluation
Hospitalize Any
Until the investigation is complete, the child needs to be in a safe setting.4 The degree of the injury should not
enter into this
decision, at least not in children. Some children younger whose conditions have been diagnosed as probably abused were sent home, with the intention of the physician being to make a report the following day, and have returned with serious additional injuries.5 If the parents refuse hospitalization or threaten to leave the outpatient setting, the physician should know how to obtain a court order and temporarily keep the child in the custody of the hospital. In some parts of the country, child protective service workers are on call 24 hours a day and provide emergency foster home capability. Unless the child's injury requires close medical observation, placement in such an emergency receiving home is less expensive than hospitalization. Provide Preventive Services
The primary physician has an opportunity to prevent serious child abuse.6 Families at risk for family breakdown or child abuse and neglect can usually be recognized by their general inability to cope, crisis-ridden existence, history of serious mental illness, lack of physical contact or eye contact with their baby, disparaging or angry remarks about their baby, or excessive use of physical punishment. Without question, these families will need extra community services (eg, day-care centers, mental health clin¬ ics, homemaker services, health visi¬ tors, crisis nurseries) if they are to provide adequate parenting for their
children.7 The essential medical ser¬ vices are reviewed in the text that follows. The physician's main role in preven¬ tion is to act as a coordinator of medical care for the children in these families. Continuity of care should begin on the maternity ward. A physi¬ cian may foster maternal attachment to the newborn by promoting (1) contact in the delivery room, (2) a rooming-in experience, (3) continued contact with the premature or sick newborn who must remain hospital¬ ized, and (4) a nursing staff support¬ ive to the needs of the new mother. After discharge, the important pre¬ ventive services include more fre¬ quent visits to the physician's office,
early outreach visits by a public health
nurse, and close attention to the moth¬ er's needs as well as the baby's. Coun¬ seling in the areas of nutrition, disci¬ pline, accident prevention, day care, and difficult developmental phases should be emphasized. Acute illnesses may precipitate an abusive incident in such families, and therefore, they may need daily follow-up by phone or office visit. High-risk parents need telephone lifelines in times of crisis. Telephone numbers of a physician, emergency room, crisis hot line, and crisis nursery (if one exists) should be
provided. Many physicians
have already learned that assessment and counsel¬ ing around "parenting" is the most productive focus of the well-child visit. The physician's role with high-risk families is simply an intensification of this emphasis. If child abuse occurs, the family will usually be quite relieved to learn that their personal physician is sympathetic to their prob¬ lems and desires to continue to provide medical care for their chil¬ dren. THE HOSPITAL-BASED CHILD ABUSE CONSULTANT The medical specialist in child abuse and neglect (or pediatrie trauma consultant) will usually be based at a teaching hospital, children's hospital, or city/county hospital. Because of the time required for in-depth evaluations and court appearances, most physi¬ cians who provide this level of service need to have salaried positions. Since these cases tend to be stressful, a full-time commitment to this field may emotionally deplete the profes¬ sional and lead to serious job dissatis¬ faction. Therefore, many trauma con¬ sultants work only part-time in this area, share call with a colleague, and receive some of their gratification from working in other areas (eg,
ambulatory pediatrics or develop¬ mental pediatrics). The physician's
main associate in child abuse evalua¬ tion and disposition is the hospital or child protection team social worker. She usually evaluates each individual parent, family functioning, and the safety of the home. She also makes
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contact with the parents, keeps them informed on all nonmedicai matters, and may do counseling if any family crisis occurs. The usual respon¬ sibilities of a hospital-based child abuse consultant will now be ad¬ dressed.
daily
Provide Consultation to
Primary Physicians
Primary physicians (eg, house staff, attending and practicing pedia¬ tricians) vary in their ability to diag¬ nose, report, and carry out the legal requirements of child abuse. A knowl¬ edgeable physician in this field can be of great assistance in clarifying the numerous questions that arise. Phone consultation is essential and in-person consultation is required in selected cases, especially if the diagnosis is equivocal. For the physician who wants nothing to do with abusive families, the availability of a referral and
increases the likelihood that properly diagnose inflicted trauma.8 a In cases where a parent is belligerent or threatening to the hospital staff, it is critical that the consultant and hospital social worker take control of this situation and permit the primary physician to main¬ tain a supportive role with the family. The primary physician should not be made to feel that he is "caught in the middle" between the angry family and the various agencies or teams. In some hospitals, the house staff must provide all services for these patients, without consultation. Facul¬ ty backup is nonexistent or is present in name only. In other institutions, all cases are turned over to the faculty person responsible for child abuse and neglect. The house staff are not required to do anything except call the child abuse specialist. The outcome of these approaches leaves much to be desired. The first approach expects the house officer to learn by trial and error, which can be disastrous in the outcome for the child and the emotion¬ al trauma to the resident. The second approach permits the house officer to unload these cases on a specialist and leads to the false impression that consultants are available throughout the country to handle these problems. resource
he will
Neither of these approaches is reason¬ able. Any condition that affects 1% of children is within the domain of the
practicing physician. In most cases, there is ample evidence to conclude that the injuries are inflicted. The physician does not need to know who inflicted the injuries to report them.
In cases that go to court, an expert witness is rarely required. The pri¬ mary pediatrician can qualify as an expert in pediatrics and, therefore, can testify in the 90% or so of cases that are clear-cut. With support and training, the house officer can learn how to deal with such cases. With appropriate continuing medical edu¬ cation, the pediatrician who entered practice before this condition was fully delineated can be upgraded in his skills.
Report Seriously Injured Cases for the Primary Physician or Surgeon Sometimes abused children have serious injuries such as subdural hematomas or burns that require long-term hospitalization. Other chil¬ dren with inflicted injuries may initially require several days in an intensive care unit. In these situa¬ tions, it is critical that the parents are able to trust and easily relate to the physician caring for their child on a day-to-day basis. This physician must not only care for the child medically but must also become a therapist for the family. Commonly, such physi¬ cians are surgeons. The physician in such daily contact should not be placed in a position of accusing the parents of child abuse, submitting a report to child protective services, and having to testify against the parents in court. The psychological balance of the fami¬ ly and the involvement of the family in the child's long-term medical care may become too precarious if the child's surgeon or hospital physician is involved in these matters. This is an ideal situation for a child protection team pediatrician to come from the outside and to meet with the parents about the suspicion of inflicted inju¬ ries and the need to report them. They can displace their anger to him and still maintain an ongoing, positive relationship with the other physician.
Provide Expert Medical Testimony on Difficult to Prove Cases
An abused child may need to have his injuries substantiated in court to achieve ongoing protection and super¬ vision of the child.1" In routine cases, the medical testimony can be provided readily by the primary physician (the practicing physician in private cases and the house officer in nonprivate ones). However, as in all of pediatrics, some cases
require subspecialty
con¬
sultation. Children with urinary tract infections, grand mal seizures, or asthma are likely to be managed by a primary physician. By contrast, chil¬ dren with chronic renal failure, intractable seizures, or cystic fibrosis are more likely to be referred to specialists. In similar fashion, the child abuse expert should be consulted in all cases that are problematic or may require complex testimony in court. (Examples of these are children with shaking-type subdural hemato¬ mas, child abuse deaths, sexual abuse cases with no physical findings, and well-defended parents with complex explanations for inflicted injuries.) Also, young infants with mild in¬ flicted injuries but who live with parents who have serious psychopathologies are at special risk, and they may need referral to a child abuse expert. An example might be a 1year-old child with hydrocephalus, an isolated slap mark on the face, and a stepfather who is known to be violent. If such a case is not adjudicated at this stage, it is almost certain that serious abuse will ensue. Teach House Staff and Medical Students About Child Abuse and Neglect It is crucial that future pediatri¬ cians receive adequate training in this area. The best teaching strategy is direct consultation around any case currently being seen by the house officer. Guidance on proper diagnosis and management should be provided. The first time a house officer is assigned a suspected case, the consul¬ tant will usually need to conduct the interview himself, with the house offi¬ cer present. The consultant can dem¬ onstrate (1) how to elicit a pediatrie data base in suspected abuse cases, (2)
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how to inform parents of the diagno¬ sis, of the need to report it, and of what will happen as a result of that report, and (3) how to deal with the parents' anger. The importance of looking for subtle physical findings in the mouth, retina, and genital area may also warrant review. The overinvolvement in, or avoidance of, child abuse cases by a particular house offi¬ cer or staff member are issues that may also need to be addressed. Handouts and references on the specific type of child abuse should be distributed. Child abuse cases should be included in case conferences as well as grand rounds presentations. One of the core lectures for medical students who rotate through pediatrics should be on the subject of child abuse and neglect as it is a uniquely pediatrie
problem.
All house officers should be
taught
to write and submit to the appropriate agency a medical statement on an
abused child. The importance of accu¬ racy and completeness needs to be stressed. The staff pediatrician should review the house officer's report and revise it as needed. Sometimes he may need to expedite this report since there is often a 48-hour deadline. House officers should also present their cases at hospital-based child protection team meetings and partici¬ pate in the discussion and disposition planning. House officers who work in continuity clinics may elect to provide ongoing medical care and preventive services to some of these families. The stresses inherent in such an assign¬ ment will require ongoing support from the child protection team social worker, pediatrician, and coordina¬ tor.
House officers should also be pro¬ vided with courtroom experience if possible. With rehearsal or assistance by the child protection team pediatri¬ cian, their testimony can go rather
well. Ideally, the staff pediatrician will accompany them to court the first time. They can be reminded that direct examination by lawyers will go smoothly if they collect a complete data base and record it carefully with dates, times, and places. Also, they should review this document carefully before the hearing and should feel
free to refer to these notes during their testimony. It can be pointed out in advance that cross-examination by the parents' attorney will probably be unpleasant and adversarial in nature, regardless of how valid a case the physician is presenting.
enough
to
comprehend, especially
to
fearful ones. The uncomplaining child should be encouraged to express his feelings after shots and other painful
procedures. Third, parents should be included as much as possible in the child's hospital
The mother should be encour¬ aged to visit frequently and to take over the feeding of her baby at these times. Especially when children may be hospitalized for more than one week (eg, failure-to-thrive evalua¬ tions), the mother's involvement should be facilitated. If possible, she should be provided with rooming-in arrangements so she can stay over¬ night. The nursing staff can support the mother, can compliment the moth¬ er on her efforts and, in general, can build confidence in herself as a capa¬ ble parent. In the long run, this is much to the child's benefit since in most cases he will be going home with his mother. Fourth, if the child must go from the hospital to a foster home, he should be adequately prepared for this event. This transition can be worked through by play therapy and dolls. A child life worker, ward nurse, or social worker can usually carry out this task. The play therapy should cover what is going to happen to the child, with emphasis on the issues that his parents still love him, that he is not being abandoned, and that he will be safe in the foster home. care.
Improve Treatment Services
for
Abused Children Who Are
Hospitalized The majority of abused children have associated behavioral problems and developmental delays. The added stress of hospitalization can worsen these problems. The abused child can become more withdrawn and fearful. He may consider procedures, such as blood drawing, as additional abusive attacks. As for the parents, if they are treated discourteously by the hospital staff, their poor visiting patterns may become limited to occasional sweeps through the ward at midnight. If the nursing staff takes over the total feeding care of the failure to thrive child or projects an aura of rescuing a child from bad parents, a depressed mother may attempt suicide. Rejec¬ tion by the hospital staff can cause the parents to become resistant to meet¬ ing with any agency or to entering into any therapy. In extreme circum¬ stances, the parents may grab their child and flee from the hospital. There are four approaches that can help to bring about a better outcome during hospitalization of the abused child. First, a consistent environment can be provided for the child. The hospital personnel caring for the child should be as constant as possible. A particular nurse and nurse's aide can be assigned for each shift. If the parents rarely visit, a foster grandparent can be assigned to the child and can spend several hours per day holding and playing with the child. In addition, a
assignment may give added sense of security. Second, the environment should be a nurturing one. The hospital staff involved with the child should provide him with as much cuddling and posi¬ tive interaction as possible. Verbal stimulation may help to overcome some of the child's language delays. Procedures should be carefully ex¬ plained in advance to all children old constant
room
the child
an
THE CHILD PROTECTION TEAM PEDIATRICIAN
Every multidisciplinary child pro¬ tection team needs the services of a pediatrician or other primary physi¬ cian. The nonphysicians (social work¬
attorneys, psychologists, police, educators) on the team have many questions about the medical reports
ers,
that are submitted to them. The team often needs clarification of medical terminology, advice on the plausibility of explanations for various accidents, and information on the prognosis of different injuries. Any pediatrician will be able to answer the majority of these questions. The team physician does not need to be a specialist on trauma, as described in the previous section on hospital-based child abuse
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consultants. There
are not enough specialists to fill all the medi¬ cal positions that are open on child protection teams. Expertise will de¬ velop after one or two years of partic¬ ipation on the team. The team physi¬
trauma
cian may need to be available to the county protective service agency for some cases of suspected child abuse, usually families without a private physician. The physician should ex¬ pect reimbursement from the county agency for in-depth consultations if they are needed more than five times per year. As a child protection team member, the pediatrician will begin to identify some of the breakdowns that occur in child abuse management. As a child advocate, the pediatrician will recog¬ nize actions that could be taken to improve child protection team func¬ tioning. Changes that are needed in the community to deal with interagency red tape, duplication of ser¬ vices, and lack of services will become apparent. Some guidelines for dealing with these issues will now be addressed. Use Guidelines for Critical Team Decisions
The decisions on when a child should be placed in foster care and when it is safe for him to be returned to his natural home are the most important ones confronting every team. When they are made inadequately, serious repercussions can occur. Some chil¬ dren are reabused, a few are killed, and some families become lost to
follow-up, not uncommonly by moving to another community or state. Unless guidelines are used for these profes¬
sional decisions, the dilemma of com¬ passion vs control will remain unre¬ solved.11 The guidelines for the temporary placement of a child in foster care in nonaccidental trauma cases are any of the following: injuries that are severe or repeated, a child with unduly provocative or obnoxious behavior, and a parent who is dangerous (eg,
sociopathic, psychotic,
or
suicidal).
Other factors that add weight to this decision are as follows: a child who is under 1 year of age; a child who is unwanted or rejected; a family where
the parent who did not injure the child is unable to protect the child; or a family with multiple ongoing crises. In situations where the child is left in the home but the parents remain resistant to accepting intervention and treatment services, foster place¬ ment is usually necessary. Guidelines for returning the child to the natural home from foster care include all of the following: (1) Certain prerequisites must be in effect, name¬ ly, if either parent was diagnosed as being seriously disturbed on an initial psychiatric evaluation, this person must be improved on réévaluation or permanently out of the home. If the child was provocative or difficult initially, his behavior must be notably improved. (2) The parents must be cooperative in therapy, keeping ap¬ pointments and fulfilling contracts. (3) Child management must be im¬ proved, with evidence that the par¬ ents' ability to cope with their child during visits has changed for the better. (4) Crisis management must be improved. The parents must have demonstrated that they can solve crises more quickly, use community resources for help during times of crisis, and are able to avoid some crises. Guidelines for the permission of visits without professional supervi¬ sion should be similar to those for the return of a child to his natural home. These guidelines can keep an inex¬ perienced team from making some serious errors. For example, a team may become impressed with the moth¬ er's concern for her children and may permit the return of the abused child to her care. In the process, the fact that the father is a violent man and has not cooperated with therapy may be overlooked. Such an oversight can end tragically. The return of the child to the natural home requires clear-cut behavioral changes in the parents and should not be tied to any set time schedule. This understanding should be made entirely clear with the parents at the time of placement. Schedule Team Reviews of High-Priority Cases A
multidisciplinary child protection major decisions
team should review all on
child abuse management.12 Ob-
viously, if a community-based child protection team is reviewing a case regularly, the hospital-based child pro¬ tection team can usually relinquish
control of that case. When cases are not reviewed and followed up closely, certain errors are almost inevitable. New cases appear in their crisis phase and demand the immediate time and attention of the primary social work¬ er. Old cases then drop in priority and some initial evaluations may never be completed. With the passage of time and the transfer of families to new caseworkers, severe cases may blend with the minor ones. Finally, some children are returned home prema¬ turely and then some are reabused. Priorities for follow-up are needed to prevent such mistakes. Certain cases need indefinite team follow-up and review. Examples of these are cases where the team has recom¬ mended termination of parental
rights, voluntary relinquishment, or long-term foster placement. Other cases require intensive follow-up and review by the team because of the course they take. Examples are where the child has not been placed and the parents demonstrate an ongoing resistance to intervention by the appropriate agencies or where reabuse occurs in a previously confirmed case.
The timing for rescheduling a conference by the multidisciplinary team is fairly predictable. Two to three weeks before any important court hearing, the team should review cases to provide the court with recent recommendations. Also, several weeks before returning a child to his natural home from foster care, the team should examine the progress that has occurred toward making the home adequately safe. This decision may have life and death consequences. Changes in family stability and impulse control must be measurable. Priority setting in follow-up is criti¬ cal in this field. If teams try to follow up all cases of child abuse and neglect with equal time and input, the more serious cases may deteriorate. Realis¬ tically, most protective service work¬ ers do not have the perspective or time to maintain priorities on all the cases they follow up. Setting these priorities
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and
rescheduling cases for multidisci¬ plinary team review can rarely hap¬ pen in an objective way unless there is
team coordinator.11 The coordinator is usually someone with a behavioral science degree and a good understand¬ ing of community resources. a
Recommend Early Adjudication of Cases Adjudication is the legal process of decision making in a court of law
based
on
judge.
If
evidence furnished to the petition is adjudicated or sustained, the judge should then man¬ date a treatment plan that the parents must be required to follow. Unfortu¬ nately, most children who have been reported as abused never have their day in court. Without court action, some parents do not take the report seriously, they avoid meeting with their caseworker, they refuse psy¬ chiatric evaluations, or they avoid therapy. Considerable treatment time may be wasted. If the child has been placed in a foster home and the case is not adjudicated, his parents may not visit, the tenuous parent-child rela¬ tionship and bonding may deteriorate, and the child may have emotional problems develop because of his being in such limbo. Time and again, the treatment process becomes bogged down if the case has not been official¬ ly adjudicated. Going to court and sustaining a petition are critical where there is severe abuse, reabuse, a a
dangerous parent, uncooperative
par¬
ents, or the need for foster care. Over¬
all, we find it helpful to err on the side of going to court, rather than postpon¬ ing it. The main prerequisite for adjudica¬ tion is strong medical data that can stand up in court. The gathering of this data is primarily the physician's duty. The history of the injury should be obtained directly from the parents so that it cannot be ruled hearsay evidence in court. In many cases, the physician can obtain confirmation that the injury was inflicted by inter¬ viewing the child, especially if he is older than age 3 years. A complete physical examination should be per¬ formed. A radiologie bone survey should be performed routinely on all physically abused children younger
than 5 years of age, and after that age by indication only. In 15% to 20% of cases, these roentgenograms demon¬ strate unexpected fractures that help make the case more serious in the eyes of the court. Bleeding disorder tests should be obtained for any child with inflicted bruises where the parents claim their child "bruises easily." The physician's findings should be summarized in an official medical report. As it may be used in court, the accuracy and completeness of this report is important. A copy of the admission workup to the hospital or the discharge summary will not suf¬ fice because the evidence for the diag¬ nosis of child abuse is often difficult for nonmedicai people to actually locate in these highly technical docu¬ ments. A well-written medical report that focuses on the injuries, the parents' explanation for them, and the reason why these injuries had to be inflicted often convinces the parents' lawyer that his clients' case is hopeless and he then accepts ("stipulates to") the petition before the court and agrees to therapy for his client. There¬ fore, a well-written medical report may keep the physician out of court and save him time in the long run. Recommend Termination of Parental Rights When Necessary
Not all abusive families are treat¬ able. In hopeless situations, termina¬ tion of parental rights becomes a necessary alternative. Only in this way can some children be freed up for adoption rather than endure a life of endless foster homes. Because of the gravity of this recommendation, it should be made only after all other efforts have failed and the parents have demonstrated no improvement over a substantial period of time. This time period of attempted rehabilita¬ tion has yet to be defined nationally, but it is somewhere around one year. Termination of parental rights is the final approach in some 5% to 10% of cases, mainly those with serious inju¬ ries or repetitive moderate injuries. However, in some highly dangerous homes, an unwanted child may need to be removed before any injury has occurred (eg, when a parent has
murdered a previous child and now has a newborn). To obtain legal termi¬ nation of parental rights, the involved child protection team must have considered this possible outcome early and laid a convincing foundation for the court. At least three professionals from the team must support the termination, usually a child protective service worker, a physician, and a psychiatrist. The physician's evalua¬ tion must document with certainty the types of physical abuse, nutrition¬ al deprivation, or sexual abuse that have occurred. The caseworker, with the help of her supervisor and the child protection team, must design a reasonable treatment plan. This plan should be written out, reviewed with the parents, and presented to the court. The parents' failure to respond to this plan or to become involved in therapy must be brought out at review hearings. A psychiatric evaluation should buttress the social worker's conclusions and stress the following: (1) Abuse will likely continue to occur in this home; (2) the prognosis for change in the parents is poor, even with therapy; or (3) therapy would probably take more time than the child's emotional development and age can afford (eg, one year in a young child).1' If both parents have a dangerous psychiatric diagnosis and refuse therapy (or are institutional¬ ized), six months should be an adequate period of time before sched¬ uling a hearing for termination of
parental rights.
Advocate Improvements in the That Deals With Child Abuse and Neglect
Community System
The pediatrician may recognize shortcomings in the community's
evaluative and treatment services for dealing with child abuse and neglect. If he can articulate the limitations convincingly, he may help to catalyze the development of improved re¬ sources. An effective and humanistic community system will contain the following components: (1) a child protective service unit with casework¬ ers on call 24 hours a day, seven days a week, and with access to emergency foster homes; (2) a full range of
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modem treatment services that can be tailored to the individual needs of both the parents and the children; (3) a county attorney who does a thorough job of preparing child abuse cases for the juvenile court; (4) a juvenile court judge who understands both parents' and children's rights; (5) a juvenile law enforcement system with police who are helpful rather than punitive; (6) the availability of preventive services such as a crisis nursery; (ie, a 24hour-a-day facility that accepts and cares for the children of families in crisis), public health nurse services, and a mechanism for referring highrisk families to child welfare without officially reporting them. The physi¬ cian can demand that these services be available in his community. C. Henry Kempe, MD, reviewed this manu¬ script. Our child protection team social worker, Claudia A. Carroll, MSW, made suggestions on early adjudication and termination.
References 1. Annual Report of the Central Registry for Child Protection. Denver, Colorado Department of Social Services, 1975. 2. Holter JC, Friedman SB: Child abuse: Early case findings in the emergency department. Pediatrics 42:128-138, 1968. 3. Schmitt BD: The physician's evaluation, in Schmitt BD (ed): The Child Protection Team Handbook. New York, Garland Publishing, 1978, pp 39-64. 4. Kempe CH: The battered child and the hospital. Hosp Pract 44:44-57, 1969. 5. McRae KN, Ferguson CA, Lederman RS: The battered child syndrome. Can Med Assoc J 108:859-866, 1973. 6. Gray JD, Cutler CA, Dean JG, et al: Prediction and prevention of child abuse and neglect. Child Abuse Neglect 1:45-58, 1977. 7. Kempe CH: Approaches to preventing child abuse: The health visitors concept. Am J Dis Child 130:941-947, 1976. 8. Mindlin RL: Child abuse and neglect: The role of the pediatrician and the Academy. Pediatrics 54:393-395, 1974. 9. Helfer RE: Why most physicians don't get involved in child abuse and what to do about it. Child Today 4:28-32, 1975. 10. Leake HC, Smith DJ: Preparing for and testifying in a child abuse hearing. Clin Pediatr 16:1057-1063, 1977. 11. Rosenfield AA, Newberger EH: Compassion versus control: Conceptual and practical pitfalls in the broadened definition of child abuse. JAMA 237:2086-2088, 1977. 12. Schmitt BD, Loy LL: Team decisions on case management, in Schmitt BD (ed): The Child Protection Team Handbook. New York, Garland Publishing, 1978, pp 187-198. 13. Lenherr MR, Grosz CA: The coordinator's role in treatment, in Schmitt BD (ed): The Child Protection Team Handbook. New York, Garland Publishing, 1978, pp 289-299. 14. Goldstein J, Freud A, Solnit AJ: Beyond the Best Interests of the Child. New York, Macmillan Publishing Co Inc, 1973.
pediatricians are being called to undertake expanded roles in the field of child abuse and neglect, whether \s=b\ Many
on
as a
practicing pediatrician,
a
hospital\x=req-\
based child abuse consultant, or as a child protection team pediatrician. The practicing pediatrician must consider the diagnosis of child abuse and neglect, confirm the diagnosis, report all suspected cases to child protective services, hospitalize any abused child who needs protection, and provide preventive services. The hospital-based child abuse consultant should provide consultation to primary physicians, report seriously injured cases for the primary physician or surgeon, provide expert medical testimony on difficult to prove cases, teach house staff and medical students about child abuse and neglect, and improve treatment services for abused children who are hospitalized. The child protection team pediatrician will usually become involved in the broader problem of improving team decision making and the interagency system that deals with child abuse and
neglect. (Am J Dis Child 133:691-696, 1979)
Many
pediatricians
are
being
called on to accept expanded roles in the field of child abuse and neglect. The physician may be asked to join a child protection team, to serve as an expert witness for a diffi¬ cult case, or to work for improvement in community services for abusive families. The purpose of the following comments is to review the various levels of involvement of pediatricians in the problem of child abuse and
neglect.
THE PRACTICING PEDIATRICIAN
The practicing pediatrician must be able to competently diagnose the From the Department of Pediatrics, University of Colorado Medical Center, Denver.
Presented at the National Pediatric Conference, Minneapolis, June 17, 1977. Reprints not available.
abuse and neglect of a child. Regard¬ less of how many specialists are trained in this field, the recognition of child abuse will continue to be the responsibility of all primary-care phy¬ sicians and nurses. The pediatrician can also play a role in the prevention and treatment of child abuse. For optimal intervention on behalf of the abused child, the practicing pediatri¬ cian can do the five following activi¬ ties. Consider the Diagnosis of Child Abuse and Neglect
In the multitude of children seen each day, the physician must think about inflicted injuries. This is espe¬ cially important in children less than 2 years of age, where every misdiagnosis carries a great potential for fatal outcome, with repeated abuse. We should think of inflicted bruises before von Willebrand's disease, nonaccidental fractures before osteogenesis imperfecta tarda, and failure to thrive from nutritional deprivation before celiac disease. The private physician will see four to six cases of child abuse and neglect per year but may go through a decade of practice without detecting a single new case of the more exotic diseases. We must keep in mind that at least 100,000 children per year are abused in this country. Of these reported cases, approximately 85% are physically abused, 10% are sexually abused, and 5% are nutritionally abused and show failure to thrive on the basis of under¬ feeding.1 There are at least 2,000 deaths a year. These statistics do not include serious neglect of children that could easily double or triple the total number. Approximately 10% of children younger than 6 years of age seen
by
emergency
for trauma have inflicted.-
room
injuries
physicians that
were
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Confirm the Diagnosis of Child Abuse and Neglect
Sometimes the injury is pathognomonic, such as a handprint, bite mark, belt mark, or cigarette burn. On other occasions, the physician should consid¬
the diagnosis of nonaccidental trau¬ the basis of the implausibility of the history offered as to how the injury occurred. The assessment of the plausibility of the history is always a medical judgment. Profes¬ sionals from other disciplines (eg, social work, psychiatry, law enforce¬ ment, and law) are not trained or expected to make this decision.3
er
ma on
All Suspected Cases to Child Protective Services
Report
The law in all 50 states requires reporting and, thereby, guarantees that adequate family evaluation, treatment, follow-up, and proper use
of the court will occur in these cases. These actions decrease the chance of recurrence and death from abuse. No matter how accomplished a counselor he is, the physician is foolhardy to ever assume that he can manage all aspects of such cases by himself. Most hospital social workers are willing to make the verbal report for the physi¬ cian and to serve as an ongoing liaison with child protective services. Some physicians may be reluctant to report such cases because they are too close to the family, do not want to become involved with a court action, or are not absolutely certain of the diagnosis. Such a physician should refer his patient to a consultant or hospital that is willing to meet the legal obligations for suspected abuse. Abused Child Who Needs Protection During the Initial Stage of Evaluation
Hospitalize Any
Until the investigation is complete, the child needs to be in a safe setting.4 The degree of the injury should not
enter into this
decision, at least not in children. Some children younger whose conditions have been diagnosed as probably abused were sent home, with the intention of the physician being to make a report the following day, and have returned with serious additional injuries.5 If the parents refuse hospitalization or threaten to leave the outpatient setting, the physician should know how to obtain a court order and temporarily keep the child in the custody of the hospital. In some parts of the country, child protective service workers are on call 24 hours a day and provide emergency foster home capability. Unless the child's injury requires close medical observation, placement in such an emergency receiving home is less expensive than hospitalization. Provide Preventive Services
The primary physician has an opportunity to prevent serious child abuse.6 Families at risk for family breakdown or child abuse and neglect can usually be recognized by their general inability to cope, crisis-ridden existence, history of serious mental illness, lack of physical contact or eye contact with their baby, disparaging or angry remarks about their baby, or excessive use of physical punishment. Without question, these families will need extra community services (eg, day-care centers, mental health clin¬ ics, homemaker services, health visi¬ tors, crisis nurseries) if they are to provide adequate parenting for their
children.7 The essential medical ser¬ vices are reviewed in the text that follows. The physician's main role in preven¬ tion is to act as a coordinator of medical care for the children in these families. Continuity of care should begin on the maternity ward. A physi¬ cian may foster maternal attachment to the newborn by promoting (1) contact in the delivery room, (2) a rooming-in experience, (3) continued contact with the premature or sick newborn who must remain hospital¬ ized, and (4) a nursing staff support¬ ive to the needs of the new mother. After discharge, the important pre¬ ventive services include more fre¬ quent visits to the physician's office,
early outreach visits by a public health
nurse, and close attention to the moth¬ er's needs as well as the baby's. Coun¬ seling in the areas of nutrition, disci¬ pline, accident prevention, day care, and difficult developmental phases should be emphasized. Acute illnesses may precipitate an abusive incident in such families, and therefore, they may need daily follow-up by phone or office visit. High-risk parents need telephone lifelines in times of crisis. Telephone numbers of a physician, emergency room, crisis hot line, and crisis nursery (if one exists) should be
provided. Many physicians
have already learned that assessment and counsel¬ ing around "parenting" is the most productive focus of the well-child visit. The physician's role with high-risk families is simply an intensification of this emphasis. If child abuse occurs, the family will usually be quite relieved to learn that their personal physician is sympathetic to their prob¬ lems and desires to continue to provide medical care for their chil¬ dren. THE HOSPITAL-BASED CHILD ABUSE CONSULTANT The medical specialist in child abuse and neglect (or pediatrie trauma consultant) will usually be based at a teaching hospital, children's hospital, or city/county hospital. Because of the time required for in-depth evaluations and court appearances, most physi¬ cians who provide this level of service need to have salaried positions. Since these cases tend to be stressful, a full-time commitment to this field may emotionally deplete the profes¬ sional and lead to serious job dissatis¬ faction. Therefore, many trauma con¬ sultants work only part-time in this area, share call with a colleague, and receive some of their gratification from working in other areas (eg,
ambulatory pediatrics or develop¬ mental pediatrics). The physician's
main associate in child abuse evalua¬ tion and disposition is the hospital or child protection team social worker. She usually evaluates each individual parent, family functioning, and the safety of the home. She also makes
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contact with the parents, keeps them informed on all nonmedicai matters, and may do counseling if any family crisis occurs. The usual respon¬ sibilities of a hospital-based child abuse consultant will now be ad¬ dressed.
daily
Provide Consultation to
Primary Physicians
Primary physicians (eg, house staff, attending and practicing pedia¬ tricians) vary in their ability to diag¬ nose, report, and carry out the legal requirements of child abuse. A knowl¬ edgeable physician in this field can be of great assistance in clarifying the numerous questions that arise. Phone consultation is essential and in-person consultation is required in selected cases, especially if the diagnosis is equivocal. For the physician who wants nothing to do with abusive families, the availability of a referral and
increases the likelihood that properly diagnose inflicted trauma.8 a In cases where a parent is belligerent or threatening to the hospital staff, it is critical that the consultant and hospital social worker take control of this situation and permit the primary physician to main¬ tain a supportive role with the family. The primary physician should not be made to feel that he is "caught in the middle" between the angry family and the various agencies or teams. In some hospitals, the house staff must provide all services for these patients, without consultation. Facul¬ ty backup is nonexistent or is present in name only. In other institutions, all cases are turned over to the faculty person responsible for child abuse and neglect. The house staff are not required to do anything except call the child abuse specialist. The outcome of these approaches leaves much to be desired. The first approach expects the house officer to learn by trial and error, which can be disastrous in the outcome for the child and the emotion¬ al trauma to the resident. The second approach permits the house officer to unload these cases on a specialist and leads to the false impression that consultants are available throughout the country to handle these problems. resource
he will
Neither of these approaches is reason¬ able. Any condition that affects 1% of children is within the domain of the
practicing physician. In most cases, there is ample evidence to conclude that the injuries are inflicted. The physician does not need to know who inflicted the injuries to report them.
In cases that go to court, an expert witness is rarely required. The pri¬ mary pediatrician can qualify as an expert in pediatrics and, therefore, can testify in the 90% or so of cases that are clear-cut. With support and training, the house officer can learn how to deal with such cases. With appropriate continuing medical edu¬ cation, the pediatrician who entered practice before this condition was fully delineated can be upgraded in his skills.
Report Seriously Injured Cases for the Primary Physician or Surgeon Sometimes abused children have serious injuries such as subdural hematomas or burns that require long-term hospitalization. Other chil¬ dren with inflicted injuries may initially require several days in an intensive care unit. In these situa¬ tions, it is critical that the parents are able to trust and easily relate to the physician caring for their child on a day-to-day basis. This physician must not only care for the child medically but must also become a therapist for the family. Commonly, such physi¬ cians are surgeons. The physician in such daily contact should not be placed in a position of accusing the parents of child abuse, submitting a report to child protective services, and having to testify against the parents in court. The psychological balance of the fami¬ ly and the involvement of the family in the child's long-term medical care may become too precarious if the child's surgeon or hospital physician is involved in these matters. This is an ideal situation for a child protection team pediatrician to come from the outside and to meet with the parents about the suspicion of inflicted inju¬ ries and the need to report them. They can displace their anger to him and still maintain an ongoing, positive relationship with the other physician.
Provide Expert Medical Testimony on Difficult to Prove Cases
An abused child may need to have his injuries substantiated in court to achieve ongoing protection and super¬ vision of the child.1" In routine cases, the medical testimony can be provided readily by the primary physician (the practicing physician in private cases and the house officer in nonprivate ones). However, as in all of pediatrics, some cases
require subspecialty
con¬
sultation. Children with urinary tract infections, grand mal seizures, or asthma are likely to be managed by a primary physician. By contrast, chil¬ dren with chronic renal failure, intractable seizures, or cystic fibrosis are more likely to be referred to specialists. In similar fashion, the child abuse expert should be consulted in all cases that are problematic or may require complex testimony in court. (Examples of these are children with shaking-type subdural hemato¬ mas, child abuse deaths, sexual abuse cases with no physical findings, and well-defended parents with complex explanations for inflicted injuries.) Also, young infants with mild in¬ flicted injuries but who live with parents who have serious psychopathologies are at special risk, and they may need referral to a child abuse expert. An example might be a 1year-old child with hydrocephalus, an isolated slap mark on the face, and a stepfather who is known to be violent. If such a case is not adjudicated at this stage, it is almost certain that serious abuse will ensue. Teach House Staff and Medical Students About Child Abuse and Neglect It is crucial that future pediatri¬ cians receive adequate training in this area. The best teaching strategy is direct consultation around any case currently being seen by the house officer. Guidance on proper diagnosis and management should be provided. The first time a house officer is assigned a suspected case, the consul¬ tant will usually need to conduct the interview himself, with the house offi¬ cer present. The consultant can dem¬ onstrate (1) how to elicit a pediatrie data base in suspected abuse cases, (2)
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how to inform parents of the diagno¬ sis, of the need to report it, and of what will happen as a result of that report, and (3) how to deal with the parents' anger. The importance of looking for subtle physical findings in the mouth, retina, and genital area may also warrant review. The overinvolvement in, or avoidance of, child abuse cases by a particular house offi¬ cer or staff member are issues that may also need to be addressed. Handouts and references on the specific type of child abuse should be distributed. Child abuse cases should be included in case conferences as well as grand rounds presentations. One of the core lectures for medical students who rotate through pediatrics should be on the subject of child abuse and neglect as it is a uniquely pediatrie
problem.
All house officers should be
taught
to write and submit to the appropriate agency a medical statement on an
abused child. The importance of accu¬ racy and completeness needs to be stressed. The staff pediatrician should review the house officer's report and revise it as needed. Sometimes he may need to expedite this report since there is often a 48-hour deadline. House officers should also present their cases at hospital-based child protection team meetings and partici¬ pate in the discussion and disposition planning. House officers who work in continuity clinics may elect to provide ongoing medical care and preventive services to some of these families. The stresses inherent in such an assign¬ ment will require ongoing support from the child protection team social worker, pediatrician, and coordina¬ tor.
House officers should also be pro¬ vided with courtroom experience if possible. With rehearsal or assistance by the child protection team pediatri¬ cian, their testimony can go rather
well. Ideally, the staff pediatrician will accompany them to court the first time. They can be reminded that direct examination by lawyers will go smoothly if they collect a complete data base and record it carefully with dates, times, and places. Also, they should review this document carefully before the hearing and should feel
free to refer to these notes during their testimony. It can be pointed out in advance that cross-examination by the parents' attorney will probably be unpleasant and adversarial in nature, regardless of how valid a case the physician is presenting.
enough
to
comprehend, especially
to
fearful ones. The uncomplaining child should be encouraged to express his feelings after shots and other painful
procedures. Third, parents should be included as much as possible in the child's hospital
The mother should be encour¬ aged to visit frequently and to take over the feeding of her baby at these times. Especially when children may be hospitalized for more than one week (eg, failure-to-thrive evalua¬ tions), the mother's involvement should be facilitated. If possible, she should be provided with rooming-in arrangements so she can stay over¬ night. The nursing staff can support the mother, can compliment the moth¬ er on her efforts and, in general, can build confidence in herself as a capa¬ ble parent. In the long run, this is much to the child's benefit since in most cases he will be going home with his mother. Fourth, if the child must go from the hospital to a foster home, he should be adequately prepared for this event. This transition can be worked through by play therapy and dolls. A child life worker, ward nurse, or social worker can usually carry out this task. The play therapy should cover what is going to happen to the child, with emphasis on the issues that his parents still love him, that he is not being abandoned, and that he will be safe in the foster home. care.
Improve Treatment Services
for
Abused Children Who Are
Hospitalized The majority of abused children have associated behavioral problems and developmental delays. The added stress of hospitalization can worsen these problems. The abused child can become more withdrawn and fearful. He may consider procedures, such as blood drawing, as additional abusive attacks. As for the parents, if they are treated discourteously by the hospital staff, their poor visiting patterns may become limited to occasional sweeps through the ward at midnight. If the nursing staff takes over the total feeding care of the failure to thrive child or projects an aura of rescuing a child from bad parents, a depressed mother may attempt suicide. Rejec¬ tion by the hospital staff can cause the parents to become resistant to meet¬ ing with any agency or to entering into any therapy. In extreme circum¬ stances, the parents may grab their child and flee from the hospital. There are four approaches that can help to bring about a better outcome during hospitalization of the abused child. First, a consistent environment can be provided for the child. The hospital personnel caring for the child should be as constant as possible. A particular nurse and nurse's aide can be assigned for each shift. If the parents rarely visit, a foster grandparent can be assigned to the child and can spend several hours per day holding and playing with the child. In addition, a
assignment may give added sense of security. Second, the environment should be a nurturing one. The hospital staff involved with the child should provide him with as much cuddling and posi¬ tive interaction as possible. Verbal stimulation may help to overcome some of the child's language delays. Procedures should be carefully ex¬ plained in advance to all children old constant
room
the child
an
THE CHILD PROTECTION TEAM PEDIATRICIAN
Every multidisciplinary child pro¬ tection team needs the services of a pediatrician or other primary physi¬ cian. The nonphysicians (social work¬
attorneys, psychologists, police, educators) on the team have many questions about the medical reports
ers,
that are submitted to them. The team often needs clarification of medical terminology, advice on the plausibility of explanations for various accidents, and information on the prognosis of different injuries. Any pediatrician will be able to answer the majority of these questions. The team physician does not need to be a specialist on trauma, as described in the previous section on hospital-based child abuse
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consultants. There
are not enough specialists to fill all the medi¬ cal positions that are open on child protection teams. Expertise will de¬ velop after one or two years of partic¬ ipation on the team. The team physi¬
trauma
cian may need to be available to the county protective service agency for some cases of suspected child abuse, usually families without a private physician. The physician should ex¬ pect reimbursement from the county agency for in-depth consultations if they are needed more than five times per year. As a child protection team member, the pediatrician will begin to identify some of the breakdowns that occur in child abuse management. As a child advocate, the pediatrician will recog¬ nize actions that could be taken to improve child protection team func¬ tioning. Changes that are needed in the community to deal with interagency red tape, duplication of ser¬ vices, and lack of services will become apparent. Some guidelines for dealing with these issues will now be addressed. Use Guidelines for Critical Team Decisions
The decisions on when a child should be placed in foster care and when it is safe for him to be returned to his natural home are the most important ones confronting every team. When they are made inadequately, serious repercussions can occur. Some chil¬ dren are reabused, a few are killed, and some families become lost to
follow-up, not uncommonly by moving to another community or state. Unless guidelines are used for these profes¬
sional decisions, the dilemma of com¬ passion vs control will remain unre¬ solved.11 The guidelines for the temporary placement of a child in foster care in nonaccidental trauma cases are any of the following: injuries that are severe or repeated, a child with unduly provocative or obnoxious behavior, and a parent who is dangerous (eg,
sociopathic, psychotic,
or
suicidal).
Other factors that add weight to this decision are as follows: a child who is under 1 year of age; a child who is unwanted or rejected; a family where
the parent who did not injure the child is unable to protect the child; or a family with multiple ongoing crises. In situations where the child is left in the home but the parents remain resistant to accepting intervention and treatment services, foster place¬ ment is usually necessary. Guidelines for returning the child to the natural home from foster care include all of the following: (1) Certain prerequisites must be in effect, name¬ ly, if either parent was diagnosed as being seriously disturbed on an initial psychiatric evaluation, this person must be improved on réévaluation or permanently out of the home. If the child was provocative or difficult initially, his behavior must be notably improved. (2) The parents must be cooperative in therapy, keeping ap¬ pointments and fulfilling contracts. (3) Child management must be im¬ proved, with evidence that the par¬ ents' ability to cope with their child during visits has changed for the better. (4) Crisis management must be improved. The parents must have demonstrated that they can solve crises more quickly, use community resources for help during times of crisis, and are able to avoid some crises. Guidelines for the permission of visits without professional supervi¬ sion should be similar to those for the return of a child to his natural home. These guidelines can keep an inex¬ perienced team from making some serious errors. For example, a team may become impressed with the moth¬ er's concern for her children and may permit the return of the abused child to her care. In the process, the fact that the father is a violent man and has not cooperated with therapy may be overlooked. Such an oversight can end tragically. The return of the child to the natural home requires clear-cut behavioral changes in the parents and should not be tied to any set time schedule. This understanding should be made entirely clear with the parents at the time of placement. Schedule Team Reviews of High-Priority Cases A
multidisciplinary child protection major decisions
team should review all on
child abuse management.12 Ob-
viously, if a community-based child protection team is reviewing a case regularly, the hospital-based child pro¬ tection team can usually relinquish
control of that case. When cases are not reviewed and followed up closely, certain errors are almost inevitable. New cases appear in their crisis phase and demand the immediate time and attention of the primary social work¬ er. Old cases then drop in priority and some initial evaluations may never be completed. With the passage of time and the transfer of families to new caseworkers, severe cases may blend with the minor ones. Finally, some children are returned home prema¬ turely and then some are reabused. Priorities for follow-up are needed to prevent such mistakes. Certain cases need indefinite team follow-up and review. Examples of these are cases where the team has recom¬ mended termination of parental
rights, voluntary relinquishment, or long-term foster placement. Other cases require intensive follow-up and review by the team because of the course they take. Examples are where the child has not been placed and the parents demonstrate an ongoing resistance to intervention by the appropriate agencies or where reabuse occurs in a previously confirmed case.
The timing for rescheduling a conference by the multidisciplinary team is fairly predictable. Two to three weeks before any important court hearing, the team should review cases to provide the court with recent recommendations. Also, several weeks before returning a child to his natural home from foster care, the team should examine the progress that has occurred toward making the home adequately safe. This decision may have life and death consequences. Changes in family stability and impulse control must be measurable. Priority setting in follow-up is criti¬ cal in this field. If teams try to follow up all cases of child abuse and neglect with equal time and input, the more serious cases may deteriorate. Realis¬ tically, most protective service work¬ ers do not have the perspective or time to maintain priorities on all the cases they follow up. Setting these priorities
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and
rescheduling cases for multidisci¬ plinary team review can rarely hap¬ pen in an objective way unless there is
team coordinator.11 The coordinator is usually someone with a behavioral science degree and a good understand¬ ing of community resources. a
Recommend Early Adjudication of Cases Adjudication is the legal process of decision making in a court of law
based
on
judge.
If
evidence furnished to the petition is adjudicated or sustained, the judge should then man¬ date a treatment plan that the parents must be required to follow. Unfortu¬ nately, most children who have been reported as abused never have their day in court. Without court action, some parents do not take the report seriously, they avoid meeting with their caseworker, they refuse psy¬ chiatric evaluations, or they avoid therapy. Considerable treatment time may be wasted. If the child has been placed in a foster home and the case is not adjudicated, his parents may not visit, the tenuous parent-child rela¬ tionship and bonding may deteriorate, and the child may have emotional problems develop because of his being in such limbo. Time and again, the treatment process becomes bogged down if the case has not been official¬ ly adjudicated. Going to court and sustaining a petition are critical where there is severe abuse, reabuse, a a
dangerous parent, uncooperative
par¬
ents, or the need for foster care. Over¬
all, we find it helpful to err on the side of going to court, rather than postpon¬ ing it. The main prerequisite for adjudica¬ tion is strong medical data that can stand up in court. The gathering of this data is primarily the physician's duty. The history of the injury should be obtained directly from the parents so that it cannot be ruled hearsay evidence in court. In many cases, the physician can obtain confirmation that the injury was inflicted by inter¬ viewing the child, especially if he is older than age 3 years. A complete physical examination should be per¬ formed. A radiologie bone survey should be performed routinely on all physically abused children younger
than 5 years of age, and after that age by indication only. In 15% to 20% of cases, these roentgenograms demon¬ strate unexpected fractures that help make the case more serious in the eyes of the court. Bleeding disorder tests should be obtained for any child with inflicted bruises where the parents claim their child "bruises easily." The physician's findings should be summarized in an official medical report. As it may be used in court, the accuracy and completeness of this report is important. A copy of the admission workup to the hospital or the discharge summary will not suf¬ fice because the evidence for the diag¬ nosis of child abuse is often difficult for nonmedicai people to actually locate in these highly technical docu¬ ments. A well-written medical report that focuses on the injuries, the parents' explanation for them, and the reason why these injuries had to be inflicted often convinces the parents' lawyer that his clients' case is hopeless and he then accepts ("stipulates to") the petition before the court and agrees to therapy for his client. There¬ fore, a well-written medical report may keep the physician out of court and save him time in the long run. Recommend Termination of Parental Rights When Necessary
Not all abusive families are treat¬ able. In hopeless situations, termina¬ tion of parental rights becomes a necessary alternative. Only in this way can some children be freed up for adoption rather than endure a life of endless foster homes. Because of the gravity of this recommendation, it should be made only after all other efforts have failed and the parents have demonstrated no improvement over a substantial period of time. This time period of attempted rehabilita¬ tion has yet to be defined nationally, but it is somewhere around one year. Termination of parental rights is the final approach in some 5% to 10% of cases, mainly those with serious inju¬ ries or repetitive moderate injuries. However, in some highly dangerous homes, an unwanted child may need to be removed before any injury has occurred (eg, when a parent has
murdered a previous child and now has a newborn). To obtain legal termi¬ nation of parental rights, the involved child protection team must have considered this possible outcome early and laid a convincing foundation for the court. At least three professionals from the team must support the termination, usually a child protective service worker, a physician, and a psychiatrist. The physician's evalua¬ tion must document with certainty the types of physical abuse, nutrition¬ al deprivation, or sexual abuse that have occurred. The caseworker, with the help of her supervisor and the child protection team, must design a reasonable treatment plan. This plan should be written out, reviewed with the parents, and presented to the court. The parents' failure to respond to this plan or to become involved in therapy must be brought out at review hearings. A psychiatric evaluation should buttress the social worker's conclusions and stress the following: (1) Abuse will likely continue to occur in this home; (2) the prognosis for change in the parents is poor, even with therapy; or (3) therapy would probably take more time than the child's emotional development and age can afford (eg, one year in a young child).1' If both parents have a dangerous psychiatric diagnosis and refuse therapy (or are institutional¬ ized), six months should be an adequate period of time before sched¬ uling a hearing for termination of
parental rights.
Advocate Improvements in the That Deals With Child Abuse and Neglect
Community System
The pediatrician may recognize shortcomings in the community's
evaluative and treatment services for dealing with child abuse and neglect. If he can articulate the limitations convincingly, he may help to catalyze the development of improved re¬ sources. An effective and humanistic community system will contain the following components: (1) a child protective service unit with casework¬ ers on call 24 hours a day, seven days a week, and with access to emergency foster homes; (2) a full range of
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modem treatment services that can be tailored to the individual needs of both the parents and the children; (3) a county attorney who does a thorough job of preparing child abuse cases for the juvenile court; (4) a juvenile court judge who understands both parents' and children's rights; (5) a juvenile law enforcement system with police who are helpful rather than punitive; (6) the availability of preventive services such as a crisis nursery; (ie, a 24hour-a-day facility that accepts and cares for the children of families in crisis), public health nurse services, and a mechanism for referring highrisk families to child welfare without officially reporting them. The physi¬ cian can demand that these services be available in his community. C. Henry Kempe, MD, reviewed this manu¬ script. Our child protection team social worker, Claudia A. Carroll, MSW, made suggestions on early adjudication and termination.
References 1. Annual Report of the Central Registry for Child Protection. Denver, Colorado Department of Social Services, 1975. 2. Holter JC, Friedman SB: Child abuse: Early case findings in the emergency department. Pediatrics 42:128-138, 1968. 3. Schmitt BD: The physician's evaluation, in Schmitt BD (ed): The Child Protection Team Handbook. New York, Garland Publishing, 1978, pp 39-64. 4. Kempe CH: The battered child and the hospital. Hosp Pract 44:44-57, 1969. 5. McRae KN, Ferguson CA, Lederman RS: The battered child syndrome. Can Med Assoc J 108:859-866, 1973. 6. Gray JD, Cutler CA, Dean JG, et al: Prediction and prevention of child abuse and neglect. Child Abuse Neglect 1:45-58, 1977. 7. Kempe CH: Approaches to preventing child abuse: The health visitors concept. Am J Dis Child 130:941-947, 1976. 8. Mindlin RL: Child abuse and neglect: The role of the pediatrician and the Academy. Pediatrics 54:393-395, 1974. 9. Helfer RE: Why most physicians don't get involved in child abuse and what to do about it. Child Today 4:28-32, 1975. 10. Leake HC, Smith DJ: Preparing for and testifying in a child abuse hearing. Clin Pediatr 16:1057-1063, 1977. 11. Rosenfield AA, Newberger EH: Compassion versus control: Conceptual and practical pitfalls in the broadened definition of child abuse. JAMA 237:2086-2088, 1977. 12. Schmitt BD, Loy LL: Team decisions on case management, in Schmitt BD (ed): The Child Protection Team Handbook. New York, Garland Publishing, 1978, pp 187-198. 13. Lenherr MR, Grosz CA: The coordinator's role in treatment, in Schmitt BD (ed): The Child Protection Team Handbook. New York, Garland Publishing, 1978, pp 289-299. 14. Goldstein J, Freud A, Solnit AJ: Beyond the Best Interests of the Child. New York, Macmillan Publishing Co Inc, 1973.
